Documentation in nursing is a key factor in our role and responsibility as a patient care advocates. It is critical for determining if the standard of care was rendered to a patient to defend prior nursing actions. Failure to chart, omissions, and poor communication are hard to defend.

Whether you are a seasoned nurse or a new grad, here are 17 tips worth reviewing:

A better option is “MD paged, assessment findings discussed, and no additional orders at this time.”

  1. Be extra careful when you think you are "too busy." It is ironic that it is at your busiest hour(s) that the importance of documenting is the most crucial. Be aware of critical times such as:

    • abnormal vital signs
    • codes
    • transfers
    • change of nursing shift or patient hand offs
    • taking verbal orders
    • noting physician’s orders
    • verifying medication orders
  2. Remember that critical values should be reported to a nurse within 15 minutes of lab verification.

  3. The nurse must report critical values to the physician within 30 minutes. If the physician can’t be reached, follow the facility’s fail safe plan.

  4. Avoid general statements. Beware of general statements that can be misconstrued. For example, you wrote “Dr. Smith called.” Did you mean:

    • you called and are waiting for a return phone call?
    • the physician called the nurse?
    • the nurse called and spoke to physician?
       

    A better option is “MD paged, assessment findings discussed, and no additional orders at this time.”

  5. Some facilities use nursing charts by exception. They indicate findings are “within defined limits” (WDL) unless otherwise noted. Know these defined limits. Charting by exception requires selecting “abnormal” and writing applicable text. In such cases, text will be carefully scrutinized.

  6. Regardless of the charting method used, nursing documentation must be:

    • Objective
    • Legible
    • Free of grammatical/spelling errors
    • Free of errors/erasures
    • Completed in blue or black ink
    • Accurate
       
  7. Late entries and any corrections entered should be per policy and procedure.

  8. Allergies should be highlighted and flow sheets filled out completely.

  9. No charting should be done in advance. 

  10. Charting patterns including flow sheets will be reviewed. “Too perfect” charting may raise doubts. Patient assessment such as fall risk or skin assessments must be carefully performed and documented. Failing to do so is a common error.

  11. Documentation should include staff notified and steps taken. Careful nursing assessment makes spotting changes in the patient’s condition easier. One recommendation is the DARE approach: document Data, Action, Response, and Evaluation. The RN is responsible for analyzing data.           

  12. Consult the nursing policy and procedure for accepted abbreviations. Sign each entry correctly, including date and time. An illegible signature may lead to all nurses on duty being named in order to “cast a wide net.”  Date and time are crucial when creating a chronology of events.  

  13. Take caution with frequent flyers.  It is easy to spot staff’s judgment. The nurse applied oxygen on one patient complaining of an impending sense of doom and documented, “Patient recovered from her previous little episode.” It was the last entry before the patient died.

  14. Evaluate any new onset of pain. One patient suddenly complained of a new onset of debilitating headache after he fell and hit his head in the hospital. This is documented as a “migraine” although there is no previous history of migraines. 12 hours later, a CT scan revealed brain stem herniation. 

  15. Hospital bills will be audited for items such as tubing charges, etc. to determine if policy and procedure was followed to prevent infections.

  16. Always use a disclaimer. Privacy issues include retaining back-up records for prescribed time and avoiding fax and e-mail when possible.

  17. The statute of limitation is typically 2 years. Medical malpractice cases may be filed up to the end of these 2 years. It may take several more years before a potential case goes to trial. Hence, a nurse may still be testifying long after the events.

To avoid all these troubles, it is important that you pay attention to nursing documentation. It may not just save your patients' lives—it might save your career, too.

Do you have other tips to help out with nursing documentation? Tell us about them in the comments!